APPENDIX B - Los Angeles County, California
APPENDIX ADEPARTMENT OF HEALTH SERVICESREQUIRED FORMSFORREQUEST FOR STATEMENT OF QUALIFICATIONS(RFSQ) Radiation Therapy ServicesAvailable only as electronic fillable forms in the DHSContracts and Grants Portal at : To use the fillable form features in the Word document forms, youmust restrict editing in the developer tab prior to filling in the form.ExhibitsPageBUSINESS FORMS1VENDOR’S ORGANIZATION QUESTIONNAIRE/AFFIDAVIT ANDCBE INFORMATION12PROSPECTIVE CONTRACTOR REFERENCES 43CERTIFICATION OF NO CONFLICT OF INTEREST54FAMILIARITY WITH THE COUNTY LOBBYIST ORDINANCE CERTIFICATION.65VENDOR’S EEO CERTIFICATION86ATTESTATION OF WILLINGNESS TO CONSIDER GAIN/GROWPARTICIPANTS97CONTRACTOR EMPLOYEE JURY SERVICE PROGRAM -CERTIFICATION FORM AND APPLICATION FOR EXCEPTION108CERTIFICATION OF COMPLIANCE WITH THE COUNTY’SDEFAULTED PROPERTY TAX REDUCTION PROGRAM1192004 NONPROFIT INTEGRITY ACT (SB 1262, CHAPTER 919)CHARITABLE CONTRIBUTIONS CERTIFICATION1210CERTIFICATION FORM REQUIRED FOR SOLICITATIONS USING FEDERAL FUNDSCERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY &VOLUNTARY EXCLUSION – LOWER TIERED COVERED TRANSACTIONS(2 C.F.R. PART 376)1311ZERO TOLERANCE HUMAN TRAFFICKING POLICYZERO TOLERANCE HUMAN TRAFFICKING POLICY CERTIFICATION15REQUIRED FORMS - EXHIBIT 1VENDOR’S ORGANIZATION QUESTIONNAIRE/AFFIDAVITAND CBE INFORMATIONPage 1 of 3Please complete, date and sign this form. The person signing the form must be authorized to sign on behalf of the Vendor and to bind the applicant in a Master Agreement.1.If your firm is a corporation or limited liability company (LLC), state its legal name (as found in your Articles of Incorporation) and State of incorporation: NameStateYear Inc. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????2.If your firm is a limited partnership or a sole proprietorship, state the name of the proprietor or managing partner: FORMTEXT ?????3.If your firm is doing business under one or more DBAs, please list all DBAs and the County(s) of registration:NameCounty of RegistrationYr. became DBA FORMTEXT ????? FORMTEXT ????? FORMTEXT ????NameCounty of RegistrationYr. became DBA FORMTEXT ????? FORMTEXT ????? FORMTEXT ????NameCounty of RegistrationYr. became DBA FORMTEXT ????? FORMTEXT ????? FORMTEXT ????4.Is your firm wholly or majority owned by, or a subsidiary of, another firm? FORMCHECKBOX No FORMCHECKBOX Yes If yes,Name of parent firm: FORMTEXT ?????State of incorporation or registration of parent firm: FORMTEXT ?????5.Please list any other names your firm has done business as within the last five (5) years.NameYr. of Name Change FORMTEXT ????? FORMTEXT ????NameYr. of Name Change FORMTEXT ????? FORMTEXT ????NameYr. of Name Change FORMTEXT ????? FORMTEXT ????Page 2 of 36.Indicate if your firm is involved in any pending acquisition/merger, including the associated company name. If not applicable, so indicate below. FORMTEXT ?????Vendor acknowledges and certifies that it meets and will comply with all of the Minimum Mandatory Requirements listed in Paragraph 1.4 – Vendor’s Minimum Qualifications, of this Request for Statement of Qualifications. CBE INFORMATION FIRM/ORGANIZATION INFORMATION: The information requested below is for statistical purposes only. On final analysis and consideration of award, contractor/vendor will be selected without regard to race/ethnicity, color, religion, sex, national origin, age, sexual orientation or disability.Business Structure: FORMCHECKBOX Sole Proprietorship FORMCHECKBOX Partnership FORMCHECKBOX Corporation FORMCHECKBOX Non-Profit FORMCHECKBOX Franchise FORMCHECKBOX Other (Please Specify) FORMTEXT ?????Number of California Employees: FORMTEXT ????? Total Number of Employees of Firm (including owners): FORMTEXT ?????Race/Ethnic Composition of Firm. Please distribute the total number of employees of Firm into the following categories:Race/Ethnic CompositionOwners/Partners/Associate PartnersManagersStaffMaleFemaleMaleFemaleMaleFemaleBlack/African American FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Hispanic/Latino FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Asian or Pacific Islander FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????American Indian FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Filipino FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????White FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????II. PERCENTAGE OF OWNERSHIP IN FIRM: Please indicate by percentage (%) how ownership of the firm is distributed.Black/African AmericanHispanic/ LatinoAsian or Pacific IslanderAmerican IndianFilipinoWhiteMen FORMTEXT ?????% FORMTEXT ?????% FORMTEXT ?????% FORMTEXT ?????% FORMTEXT ?????% FORMTEXT ?????%Women FORMTEXT ?????% FORMTEXT ?????% FORMTEXT ?????% FORMTEXT ?????% FORMTEXT ?????% FORMTEXT ?????%III. CERTIFICATION AS MINORITY, WOMEN, DISADVANTAGED, AND DISABLED VETERAN BUSINESS ENTERPRISES: If your firm is currently certified as a minority, women, disadvantaged or disabled veteran owned business enterprise by a public agency, complete the following and attach a copy of your proof of certification. (Use back of form, if necessary.)Agency NameMinorityWomenDisadvantagedDisabled VeteranOther FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Page 3 of 3IV. CERTIFIED BY THE DEPARTMENT OF CONSUMER AND BUSINESS AFFAIRS (DCBA) IN THE PREFERENCE PROGRAMS INDICATED BELOW: FORMCHECKBOX Local Small Business Enterprise FORMCHECKBOX Social Enterprise FORMCHECKBOX Disabled Veteran Business EnterpriseVendor further acknowledges that if any false, misleading, incomplete, or deceptively unresponsive statements in connection with this SOQ are made, the SOQ may be rejected. The evaluation and determination in this area shall be at the Director’s sole judgment and his/her judgment shall be final.DECLARATION: I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE.Proposer’s Name FORMTEXT ?????Address FORMTEXT ?????E-mail address:Telephone number:Fax number: FORMTEXT ????? FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT ???- FORMTEXT ???- FORMTEXT ????On behalf of FORMTEXT ????? (Vendor’s name), I FORMTEXT ????? (Name of Vendor’s authorized representative), certify that the information contained in this Vendor’s Organization Questionnaire/Affidavit is true and correct to the best of my information and belief._________________________________________SignatureTitleCA Secretary of StateEntity Number FORMTEXT ????? FORMTEXT ?????DateIRS Employer Identification NumberCounty WebVen Number FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????REQUIRED FORMS - EXHIBIT 2PROSPECTIVE CONTRACTOR REFERENCESContractor’s Name: FORMTEXT ?????List three (3) references where the same or similar scope of services were provided in order to meet the Minimum Qualifications stated in thissolicitation.Name of Firm: FORMTEXT ?????Address of Firm: FORMTEXT ?????Contact Person: FORMTEXT ????? Telephone #: FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ?????Specific Date of Contract – From - To FORMTEXT ??- FORMTEXT ??- FORMTEXT ???? - FORMTEXT ??- FORMTEXT ??- FORMTEXT ????Name or Contract No. FORMTEXT ?????Type of Service: FORMTEXT ?????Annual Dollar Amount:$ FORMTEXT ?????2. Name of Firm: FORMTEXT ?????Address of Firm: FORMTEXT ?????Contact Person: FORMTEXT ????? Telephone #: FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ?????Specific Date of Contract – From - To FORMTEXT ??- FORMTEXT ??- FORMTEXT ???? - FORMTEXT ??- FORMTEXT ??- FORMTEXT ????Name or Contract No. FORMTEXT ?????Type of Service: FORMTEXT ?????Annual Dollar Amount:$ FORMTEXT ????? Name of Firm: FORMTEXT ?????Address of Firm: FORMTEXT ?????Contact Person: FORMTEXT ????? Telephone #: FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ?????Specific Date of Contract – From - To FORMTEXT ??- FORMTEXT ??- FORMTEXT ???? - FORMTEXT ??- FORMTEXT ??- FORMTEXT ????Name or Contract No. FORMTEXT ?????Type of Service: FORMTEXT ?????Annual Dollar Amount:$ FORMTEXT ?????REQUIRED FORMS - EXHIBIT 3CERTIFICATION OF NO CONFLICT OF INTERESTThe Los Angeles County Code, Section 2.180.010, provides as follows:CONTRACTS PROHIBITEDNotwithstanding any other section of this Code, the County shall not contract with, and shall reject any SOQs submitted by, the persons or entities specified below, unless the Board of Supervisors finds that special circumstances exist which justify the approval of such contract:Employees of the County or of public agencies for which the Board of Supervisors is the governing body;Profit-making firms or businesses in which employees described in number 1 serve as officers, principals, partners, or major shareholders;Persons who, within the immediately preceding 12 months, came within the provisions of number 1, and who:Were employed in positions of substantial responsibility in the area of service to be performed by the contract; orParticipated in any way in developing the contract or its service specifications; and4.Profit-making firms or businesses in which the former employees, described in number 3, serve as officers, principals, partners, or major shareholders. Contracts submitted to the Board of Supervisors for approval or ratification shall be accompanied by an assurance by the submitting department, district or agency that the provisions of this section have not been violated.Vendor Name: FORMTEXT ?????Vendor Official Title: FORMTEXT ?????Date: FORMTEXT ??- FORMTEXT ??- FORMTEXT ???? ____________________________________________________Official’s SignatureREQUIRED FORMS - EXHIBIT 4FAMILIARITY WITH THE COUNTY LOBBYIST ORDINANCE CERTIFICATIONThe Vendor certifies that:Vendor is familiar with the terms of the County of Los Angeles Lobbyist Ordinance, Los Angeles Code Chapter 2.160;Each County Lobbyist, as defined by Los Angeles County Code Section 2.160.010, retained by the Vendor is in full compliance with Chapter 2.160 of the Los Angeles County Code; andEach such County Lobbyist retained by the Vendor is not on the Executive Office’s List of Terminated Registered Lobbyists as part of their SOQ.Signature:_________________________________ Date:__________________________REQUIRED FORMS - EXHIBIT 5VENDOR’S EEO CERTIFICATIONCompany Name: FORMTEXT ?????Address: FORMTEXT ?????Internal Revenue Service Employer Identification Number: FORMTEXT ?????GENERALIn accordance with provisions of the County Code of the County of Los Angeles, the Vendor certifies and agrees that all persons employed by such firm, its affiliates, subsidiaries, or holding companies are and will be treated equally by the firm without regard to or because of race, religion, ancestry, national origin, or sex and in compliance with all anti-discrimination laws of the United States of America and the State of California.CERTIFICATIONYESNOVendor has written policy statement prohibitingdiscrimination in all phases of employment. FORMCHECKBOX FORMCHECKBOX Vendor periodically conducts a self-analysis orutilization analysis of its work force. FORMCHECKBOX FORMCHECKBOX Vendor has a system for determining if its employmentpractices are discriminatory against protected groups. FORMCHECKBOX FORMCHECKBOX When problem areas are identified in employment practices,Vendor has a system for taking reasonable corrective action to include establishment of goal and/or timetables. FORMCHECKBOX FORMCHECKBOX ________________________________________________ SignatureDate: FORMTEXT ??- FORMTEXT ??- FORMTEXT ????Name of Signer: FORMTEXT ????? Title: FORMTEXT ?????REQUIRED FORMS - EXHIBIT 6ATTESTATION OF WILLINGNESS TO CONSIDERGAIN/GROW PARTICIPANTSAs a threshold requirement for consideration for contract award, Vendor shall demonstrate a proven record for hiring GAIN/GROW participants or shall attest to a willingness to consider GAIN/GROW participants for any future employment opening if they meet the minimum qualifications for that opening. Additionally, Vendor shall attest to a willingness to provide employed GAIN/GROW participants access to the Vendor’s employee mentoring program, if available, to assist these individuals in obtaining permanent employment and/or promotional opportunities. To report all job openings with job requirements to obtain qualified GAIN/GROW participants as potential employment candidates, Contractor shall email: GAINGROW@dpss.Vendors unable to meet this requirement shall not be considered for contract award.Vendor shall complete all of the following information, sign where indicated below, and return this form with their SOQ.Vendor has a proven record of hiring GAIN/GROW participants. FORMCHECKBOX YES (subject to verification by County) FORMCHECKBOX NO Vendor is willing to provide DPSS with all job openings and job requirements to consider GAIN/GROW participants for any future employment openings if the GAIN/GROW participant meets the minimum qualifications for the opening. “Consider” means that Vendor is willing to interview qualified GAIN/GROW participants. FORMCHECKBOX YES FORMCHECKBOX NOVendor is willing to provide employed GAIN/GROW participants access to its employee-mentoring program, if available. FORMCHECKBOX YES FORMCHECKBOX NO FORMCHECKBOX N/A (Program not available)Vendor Organization: FORMTEXT ?????Signature: ____________________________________________________________________Type or Print Name: FORMTEXT ?????Type or Print Title: FORMTEXT ????? Date: FORMTEXT ??- FORMTEXT ??- FORMTEXT ????Telephone Number: FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ?????FAX Number: FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? REQUIRED FORMS - EXHIBIT 7COUNTY OF LOS ANGELES CONTRACTOR EMPLOYEE JURY SERVICE PROGRAMCERTIFICATION FORM AND APPLICATION FOR EXCEPTION The County’s solicitation for this Request for Statement of Qualifications is subject to the County of Los Angeles Contractor Employee Jury Service Program (Program), Los Angeles County Code, Chapter 2.203. All vendors, whether a contractor or subcontractor, must complete this form to either certify compliance or request an exception from the Program requirements. Upon review of the submitted form, the County department will determine, in its sole discretion, whether the vendor is exempted from the pany Name: FORMTEXT ?????Company Address: FORMTEXT ?????City: FORMTEXT ????? State: FORMTEXT ?? Zip Code: FORMTEXT ?????Telephone Number: FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ?????Solicitation For FORMTEXT ????? Services:If you believe the Jury Service Program does not apply to your business, check the appropriate box in Part I (attach documentation to support your claim); or, complete Part II to certify compliance with the Program. Whether you complete Part I or Part II, please sign and date this form below.Part I: Jury Service Program is Not Applicable to My Business FORMCHECKBOX My business does not meet the definition of “contractor,” as defined in the Program, as it has not received an aggregate sum of $50,000 or more in any 12-month period under one or more County contracts or subcontracts (this exception is not available if the contract itself will exceed $50,000). I understand that the exception will be lost and I must comply with the Program if my revenues from the County exceed an aggregate sum of $50,000 in any 12-month period. FORMCHECKBOX My business is a small business as defined in the Program. It 1) has ten or fewer employees; and, 2) has annual gross revenues in the preceding twelve months which, if added to the annual amount of this contract, are $500,000 or less; and, 3) is not an affiliate or subsidiary of a business dominant in its field of operation, as defined below. I understand that the exception will be lost and I must comply with the Program if the number of employees in my business and my gross annual revenues exceed the above limits. “Dominant in its field of operation” means having more than ten employees and annual gross revenues in the preceding twelve months, which, if added to the annual amount of the contract awarded, exceed $500,000.“Affiliate or subsidiary of a business dominant in its field of operation” means a business which is at least 20 percent owned by a business dominant in its field of operation, or by partners, officers, directors, majority stockholders, or their equivalent, of a business dominant in that field of operation. FORMCHECKBOX My business is subject to a Collective Bargaining Agreement (attach agreement) that expressly provides that it supersedes all provisions of the Program.ORPart II: Certification of Compliance FORMCHECKBOX My business has and adheres to a written policy that provides, on an annual basis, no less than five days of regular pay for actual jury service for full-time employees of the business who are also California residents, or my company will have and adhere to such a policy prior to award of the contract.I declare under penalty of perjury under the laws of the State of California that the information stated above is true and correct.Print Name: FORMTEXT ?????Title: FORMTEXT ?????Signature:Date: FORMTEXT ??- FORMTEXT ??- FORMTEXT ????REQUIRED FORMS - EXHIBIT 8 CERTIFICATION OF COMPLIANCE WITH THE COUNTY'S DEFAULTED PROPERTY TAX REDUCTION PROGRAMCompany Name: FORMTEXT ?????Company Address: FORMTEXT ?????City: FORMTEXT ????? State: FORMTEXT ?? Zip Code: FORMTEXT ?????Telephone Number: FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ?????The following definitions shall be applicable to the program.Los Angeles County Code Chapter 2.206.020 A. “Contractor” shall mean any person, firm, corporation, partnership, or combination thereof, which submits a bid or proposal or enters into a contract or agreement with the County.Los Angeles County Code Chapter 2.206.020 C. “County Property Taxes” shall mean any property tax obligation on the County’s secured or unsecured roll; except for tax obligations on the secured roll with respect to property held by a Contractor in a trust or fiduciary capacity or otherwise not beneficially owned by the Contractor.The Vendor certifies that: FORMCHECKBOX It is familiar with the terms of the County of Los Angeles Defaulted Property Tax Reduction Program, Los Angeles County Code Chapter 2.206; ANDTo the best of its knowledge, after a reasonable inquiry, the Vendor is not in default, as that term is defined in Los Angeles County Code Section 2.206.020.E, on any Los Angeles County property tax obligation; ANDThe Vendor agrees to comply with the County's Defaulted Property Tax Reduction Program during the term of any awarded contract.OR FORMCHECKBOX It is exempt from the County of Los Angeles Defaulted Property Tax Reduction Program, Pursuant to Los Angeles County Code Section 2.206.060, for the following reason: FORMTEXT ?????I declare under penalty of perjury under the laws of the State of California that the information stated above is true and correct.Print Name: FORMTEXT ????? Title: FORMTEXT ?????Signature:______________________________________________________ Date: FORMTEXT ??- FORMTEXT ??- FORMTEXT ????REQUIRED FORMS - EXHIBIT 9CHARITABLE CONTRIBUTIONS CERTIFICATIONCompany Name: FORMTEXT ?????Address: FORMTEXT ?????Internal Revenue Service Employer Identification Number: FORMTEXT ????? FORMCHECKBOX Vendor or Contractor is exempt from the California Nonprofit Integrity Act.California Registry of Charitable Trusts “CT” number (if applicable): FORMTEXT ?????The Nonprofit Integrity Act (SB 1262, Chapter 919) added requirements to California’s Supervision of Trustees and Fundraisers for Charitable Purposes Act which regulates those receiving and raising charitable contributions.If Vendor or Contractor is not exempt, check the Certification below that is applicable to your company. FORMCHECKBOX Vendor or Contractor has examined its activities and determined that it does not now receive or raise charitable contributions regulated under California’s Supervision of Trustees and Fundraisers for Charitable Purposes Act. If Vendor engages in activities subjecting it to those laws during the term of a County contract, it will timely comply with them and provide County a copy of its initial registration with the California State Attorney General’s Registry of Charitable Trusts when filed. OR FORMCHECKBOX Vendor or Contractor is registered with the California Registry of Charitable Trusts under the CT number listed above and is in compliance with its registration and reporting requirements under California law. Attached is a copy of its most recent filing with the Registry of Charitable Trusts as required by Title 11 California Code of Regulations, sections 300-301 and Government Code sections 12585-12586. ___________________________________________SignatureDate: FORMTEXT ??- FORMTEXT ??- FORMTEXT ????Name of Signer: FORMTEXT ?????Title: FORMTEXT ?????REQUIRED FORMS - EXHIBIT 10CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION – LOWER TIER COVERED TRANSACTIONS(2 C.F.R. PART 376)Page 1 of 2Instructions for Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion – Lower Tier Covered Transactions (2 C.F.R. Part 376)1.This certification is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that Vendor knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.2.Vendor shall provide immediate written notice to the person to whom this SOQ is submitted if at any time Vendor learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.3.The terms “covered transaction,” “debarred,” “suspended,” “ineligible,” “lower tier covered transaction,” “participant,” “person,” “primary covered transaction,” “principal,” “bid,” and “voluntarily excluded,” as used in this certification, have the meaning set out in the Definitions and Coverage sections of rules implementing Executive Order 12549. You may contact the person to which this SOQ is submitted for assistance in obtaining a copy of those regulations.4.Vendor agrees by submitting this SOQ that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is proposed for debarment under 48 C.F.R. part 9, subpart 9.4, debarred suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency with which this transaction originated.Vendor further agrees by submitting this SOQ that it will include the provision entitled “Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion – Lower Tier Covered Transactions (2 C.F.R. Part 376),” as set forth in the text of the Master Agreement attached to the Request for Statement of Qualifications, without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.Vendor acknowledges that a participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not proposed for debarment under 48 C.F.R. part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from covered transactions, unless it knows that the certification is erroneous. Vendor acknowledges that a participant may decide the method and frequency by which it determines the eligibility of its principals. Vendor acknowledges that each participant may, but is not required to, check the List of Parties Excluded from Federal Procurement and Nonprocurement Programs.Page 2 of 2Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the required certification. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.Except for transactions authorized under paragraph 4 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is proposed for debarment under 48 C.F.R. part 9, subpart 9.4, suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.Where Vendor and/or its subcontractor(s) is or are unable to certify to any of the statements in this Certification, Vendor shall attach a written explanation to its SOQ in lieu of submitting this Certification. Vendor’s written explanation shall describe the specific circumstances concerning the inability to certify. It further shall identify any owners, officers, partners, directors, other principals, employees or independent contractors of the Vendor and/or subcontractor who is currently suspended, debarred, ineligible, or excluded from securing federally funded contracts. The written explanation shall provide that person’s or those persons’ job description(s) and function(s) as they relate to the contract which is being solicited by this Request for Statement of Qualifications.Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion – Lower Tier Covered Transactions (2 C.F.R. Part 376)Vendor hereby certifies that neither it nor any of its subcontractors’ owners, officers, partners, directors, other principals, employees or independent contractors is currently debarred, suspended, proposed for debarment, declared ineligible or excluded from securing federally funded contracts by any federal department or agency.Dated: FORMTEXT ??- FORMTEXT ??- FORMTEXT ????________________________________________Signature of Authorized Representative FORMTEXT ?????___________________________________Title of Authorized Representative FORMTEXT ?????___________________________________Printed Name of Authorized RepresentativeREQUIRED FORMS - EXHIBIT 11ZERO TOLERANCE HUMAN TRAFFICKINGPOLICY CERTIFICATION Company Name: FORMTEXT ?????Company Address: FORMTEXT ?????City: FORMTEXT ????? State: FORMTEXT ?? Zip Code: FORMTEXT ?????Telephone Number: FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ?????Solicitation For FORMTEXT ????? Services:VENDOR CERTIFICATIONLos Angeles County has taken significant steps to protect victims of human trafficking by establishing a zero tolerance human trafficking policy that prohibits contractors found to have engaged in human trafficking from receiving contract awards or performing services under a County contract. Vendor acknowledges and certifies compliance with Sub-paragraph 8.59 - Compliance with County’s Zero Tolerance Human Trafficking Policy of Appendix H - Master Agreement and agrees that Vendor or a member of Vendor’s staff performing work under the Master Agreement will be in compliance. Vendor further acknowledges that noncompliance with the County's Zero Tolerance Human Trafficking Policy may result in rejection of any SOQ, or cancellation of any resultant Master Agreement, at the sole judgment of the County. I declare under penalty of perjury under the laws of the State of California that the information herein is true and correct and that I am authorized to represent this company.Print Name: FORMTEXT ?????Title: FORMTEXT ?????Signature:Date: FORMTEXT ??- FORMTEXT ??- FORMTEXT ???? ................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- los angeles county department of public health
- los angeles county preliminary change
- los angeles county pcor pdf
- los angeles county courts
- los angeles county courthouses
- los angeles county superior court
- los angeles county superior court norwalk
- los angeles county of records
- los angeles county registrar recorder website
- los angeles county records department
- los angeles county hall of records
- los angeles county recorder s office